Updated: Jun 12
By Sarah Yu
The history of the medical face mask cannot be separated from the history of germ theory, the discovery of the plague bacillus, nor from colonialism and racism in Asia. Surgeons, according to historian Nancy Tomes, first began wearing skull caps and face masks at the operating table in the 1890s. While their patients could be cleansed and shaved before procedures, surgeons and their attendants always brought “microbial life” into the operating theatre. Shaving their beards, putting on masks, and speaking as little as possible (as talking expelled germs), surgeons sacrificed their aesthetic and vocal identities “on the altar of asepsis” for their work and for humanity [Tomes, 103—4]. But it was not until the first decade of the twentieth century that the use of a mask became a widespread practice for not only doctors, but support staff, patients, and the general public.
During the Manchurian Plague Epidemic of 1910—1911, a public health crisis occurring at the geographical intersection of Russian, Japanese, and Chinese imperial ambitions, just 15 years after Russian-French and Japanese-German doctors isolated the necessary bacillus for plague infection in the British colony of Hong Kong. Wu Lien-teh (in some documents G.L. Tuck), a Malay-born British doctor in the employ of the struggling Chinese Qing Empire, hypothesised that the pneumonic form of plague as seen in Manchuria was airborne and thus could be prevented with a prophylactic barrier [Lynteris, 445]. Suggesting that a multi-layered gauze mask over the mouth and nose could protect the wearer, Wu, later appointed as the first head of a Chinese national public health bureau, disengaged from the previous racial- and class-driven war against plague during the Hong Kong outbreak that was persistent even after the bacillus discovery [Sutphen]. Humanity’s common enemy was not filth, the poor, the Chinese, or even fleas on rodents, but an airborne microbe against which humans must protect themselves and each other.
Wu’s gauzy invention became adopted, if not universally, then certainly by the transnational medical communities of East Asia. The Japanese quickly adopted wearing “layered gauze” masks during the 1918 influenza pandemic [Spinney]. They similarly became part of the necessary uniform for plague control teams in Shanxi, China, during yet another outbreak of pneumonic plague in 1917—1918. Public notices touting mask wearing as socially responsible appeared in villages, while doctors (both foreign and Chinese), assistants, police officers, and burial squads modelled their gauze masks as they went about their work.
1918, in fact, was peak mask year. Following articles published by both civilian and military doctors proving the efficacy of masks in preventing infection from diseases such as meningitis and diphtheria, the “literature was flooded with experimental studies to determine which type of mask was the most efficient” for patients and physicians, and for different types of diseases [Rockwood and O’Donoghue, 965]. Despite the medical profession’s successes at keeping infectious diseases contained in their respective clinical environments, the influenza pandemic of 1918—1919 showed the American public that prevention had to start from the individual. In some places, it became illegal to not don a mask on public transportation. Even if the studies proving the efficacy of masks seemed largely anecdotal, it did not seem to deter common Americans from donning masks of gauze throughout their daily lives [French, April 2020]. San Franciscans wore masks, took them off when infection numbers slowed, but were told to put them back on during the second wave, triggering a series protests against the government’s invasive orders that seemed to undermine personal liberty [Mak, April 2020]. Moreover, mask-wearing, along with spitting prohibition regulations, mandatory disease reporting, and other invasive forms of government control during the pandemic, seemed to have left the post-pandemic American consciousness in a wave of “collective amnesia” [Tomes, 246]. While medical researchers such as Charles Rockwood and Don O’Donoghue continued to test and refine surgical mask efficacy in experimental studies in the 1960s, masks had retreated from public view, back into operating theatre, even as they became cheaper and easier to manufacture.
Experimental studies of the effectiveness of PPE continue in the twenty-first century. Outbreaks of SARS, influenza, Ebola, and other recent diseases have allowed researchers to examine both “prophylactic efficacy” and “public perceptions and the social impact” of masks [Lynteris, 442]. But just like in the plague epidemic of 1910—1911, mask wearing today is still imbued with loud cultural and and intellectual signifiers. By wearing a mask in public, are you showing your level of scientific enlightenment, snobbery, or foreignness? Are you indicating that you are actually sick and probably should not be in public? Do you distrust your fellow bus passengers, grocery store shoppers, and other citizens?
I first put on a disposable surgical mask to go out in public on January 23, 2020, while staying with my family in Hong Kong. I’d pinched the wire tight around my nose as soon as I stepped into Hong Kong’s Mass Transit Railway concourse at my home station, until I arrived at my favourite pub about fifty minutes later to meet old friends for a beer and a chat. I hugged the familiar wait staff and my friends, and we proceeded to share a large bowl of chips and tandoori chicken skewers. When it was time to go home, we each pulled out out neatly folded masks and hopped back onto taxis or public transportation. Hong Kongers all around me were doing the same. We donned our masks to signal our understanding of social responsibility in front of strangers (after all, how could you be sure if the individual not wearing mask wasn’t out to sabotage everyone else by making them sick?), but once we reached the safety of our destinations – restaurants, bars, salons… – we took them off, comforted by their familiarity and safety as paying customers in a capitalistic society are entitled to do.
Until a mere few weeks ago, public health officials in the Western world had dismissed the use of masks as effective for the general public. I had found their reasoning annoying and frustrating from the very beginning. At no point did the authorities say that masks were ineffective at spreading contagion, per se, just that the general public was (paraphrasing for the sake of conciseness and impact) too stupid to use them properly. Forbes’ February 29 article [“No, You Do Not Need Face Masks to Prevent Coronavirus – They Might Increase Your Infection Risk”] quoted a doctor saying “If you don’t wash your hands before you take off the mask and after you take off your mask, you could increase your risk”. The Surgeon General of the United States tweeted “[Masks] are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!” I thought to myself (and told other people in my orbit), why couldn’t we recognise that masks were both useful AND that we shouldn’t hoard them? I know we should all be washing our hands and not touching our faces, but what better reminder to do those things than a really uncomfortable face covering? I tried to stick by my beliefs and took one of my precious supply of 3M masks to the grocery store for a shopping trip, only to chicken out at the last minute and left it in my car as I was scared to be looked at with suspicion and/or be called a racial slur. I reminded my acquaintances of the recent fires in my home country Australia, during which the air pollution was so bad that N95 masks were sold out at every hardware store. Surely our society was not going to tell millions of Australians affected by the fires that their self-protection efforts were also worthless?
The infantilisation of the public and dismissal of the individual’s ability to reason with common sense really… pissed me off. Are ordinary people of the Western world not smart enough to understand basic instructions about mask usage for maximum efficacy, even if we were taught? Are we not kind or humane enough to be told the honest truth – that medical professionals on the front line needed the masks more? I felt somewhat personally indignant that the results from studies conducted by our forerunner doctors would be so easily dismissed simply because they were not written for the lay audience. In the course of my own dissertation research, when I found a simple diagram for making a face mask on a public notice from Shanxi, China, I wrote a tongue-in-cheek blog post about making your own mask, as per 1918 instructions. Even I couldn’t imagine how relevant this would become over the next two months.
American healthcare authorities have finally changed their stance, and masks – of any kind – are now required in my area on public transportation and supermarkets. The zeal with which people have begun wearing masks again (after an incredible 102-year hiatus) has been at times comical. I have seen people wear masks while alone in their cars and gardening in the front yard of their half-acre properties, but as a long-time Hong Kong resident and historian of public health, I can’t help but feel vindicated. The efficacy and necessity of public health measures such as mask-wearing and prohibition of spitting (and even vaccines! Good grief.) will continue to be debated, despite advances in medical science. Social segregation by class and race will continue during crises of public health. But maybe this time, with the permanent written record of the internet and the resurgence of public shaming in social media, we could avoid the familiar collective amnesia once this pandemic passes.
Sarah Yu is also writing a dissertation about hygiene education in early 20th century China from her home office in Delaware County, PA. Find out more about her work here.
French, Paul. “In the 1918 Flu Pandemic, Not Wearing a Mask Was Illegal in Some Parts of America. What Changed?” CNN [online] www.cnn.com/2020/04/03/americas/flu-america-1918-masks-intl-hnk/index.html
Spooner, John L. “History of Surgical Face Masks”. AORN 5, no. 1 (1967). 76—80.
Lynteris, Christos. “Plague Masks: The Visual Emergence of Anti-Epidemic Personal Protection Equipment”. Medical Anthropology 37, no 6 (2018). 442—457.
Mak, Tim. “THREAD: History doesn’t repeat itself, but it rhymes”. Twitter [online] twitter.com/timkmak/status/1251936242834563073.
Rockwood, Charles A. and Don H. O’Donoghue. “The Surgical Mask: Its Development, Usage, and Efficiency: A Review of the Literature, and New Experimental Studies”. Archives of Surgery 80 (1960). 963—971.
Spinney, Laura. Pale Rider: The Spanish Flue of 1918 and How It Changed the World. Public Affairs, 2017.
Sutphen, Mary P. “Not What, but Where: Bubonic Plague and the Reception of Germ Theories in Hong Kong and Calcutta, 1894—1897”. Journal of the History of Medicine and Allied Sciences 52, no. 1 (January 1997). 81—113.
Tomes, Nancy. The Gospel of Germs: Men, Women, and the Microbe in American Life. Cambridge: Harvard University Press, 1999.
Yu, Sarah. Chinese Must Wash Their Hands Before Returning to Work. [online] www.hygiencchinahistory.wordpress.com.